Treatment of Diverticular Disease Bleeding

Management of acute lower GI bleeding from diverticular disease should start with resuscitation of the patient followed by identification of the bleeding site. Most patients either stop bleeding spontaneously, or respond to medical or less invasive measures. However, almost a quarter of these patients will require surgical intervention for treatment of their disease.

FIGURE 103-1. Contrast enema demonstration filling of the bladder due to a colovesiclefistula.

The steps in identification and treatment of a suspected colonic diverticular bleed are relatively straight-forward (Figure 103-2). It is important that after a nasogastric tube is placed that bilious aspirate devoid of blood is demonstrated. Clear fluid without bile may represent only stomach contents and brisk duodenal bleeding could still be present. Once an upper GI bleed has been ruled out, proc-toscopy can be easily performed at the bedside. This will allow evaluation of the distal 15 to 18 cm and effectively rule out that site as a source of bleeding. This is important should an emergent operation be needed without a definite site identified, as will be discussed later.

A tagged red blood cell scan is generally seen as the best initial study in determining the site of GI bleeding. In addition to being the least invasive test, it also has no detrimental affect on renal function. This is an important advantage as many patients with brisk GI bleeding are severely hypovolemic and present with an elevated creatinine. Although a nuclear scan is the least accurate in determining the specific site of bleeding, it generally does provide enough information to allow for a segmental resection if needed. It also is helpful in determining if the bleeding is originating from the superior or inferior mesenteric artery distribution. This will allow for selective catheterization of the appropriate vessel should arteriography be necessary, thus limiting IV dye load to the patient.

If bleeding continues and the patient is stable, the next step in treatment is arterial catheterization of the appropriate vessel. This will not only provide information about the specific site of bleeding (Figure 103-3), but will also allow for the infusion of vasopressin or selective embolization to control bleeding. The preceding chapter is on therapeutic radiologic approaches (see Chapter 102, "Transcatheter Management of Upper and Lower Gastrointestinal Bleeding"). If bleeding either

stops spontaneously or can be controlled with angiographic techniques but the actual diagnosis (ie, diverticular bleed, arteriovenous malformation [AVM], cancer, etc.) is in question, elective colonoscopy after bowel preparation is indicated. Some causes of bleeding, such as AVMs, can be treated with cauterization whereas cancers or polyps can be biopsied or removed.

Some clinicians advocate the use of "emergent colonoscopy" in the setting of acute hemorrhage as a single procedure for both diagnosis and treatment. Orally administered lavage permits adequate colon preparation within 2 hours. An experienced colonoscopist can reach the cecum in 90% of cases, and modalities such as elec-trocoagulation, photocoagulation, or heater probe can be used to address bleeding sites via the colonoscope. There is a separate chapter on lower GI bleeding (see Chapter 101, "Lower Gastrointestinal Bleeding"). Despite the success rate of emergent colonoscopy, we still feel that the approach outlined in figure Figure 103-2 is the best in treating patients with continuing lower gastrointestinal GI bleeding with known diverticular and no other known disease.

Indications for surgical intervention in the treatment of lower GI bleeding include (1) the need for transfusion of more than 4 units of packed red blood cells in a 24-hour period to maintain adequate hematocrit levels, (2) any patient who rebleeds during the same hospitalization, and (3) hemodynamic instability despite resuscitation efforts. In the event that the bleeding site had been demonstrated by nuclear scan, angiography, or colonoscopy, segmental colon resection is the procedure of choice. Right-sided lesions can be treated with resection and primary anastomosis even without formal preoperative bowel preparation whereas left sided lesions have traditionally required resection and diverting colostomy. Recently, several authors have advocated intraoperative colonic lavage as a method of

FIGURE 103-3. Bleeding scan showing accumulation of tagged cells in the area of the splenic flexure on the final two images.

mechanical bowel cleansing and subsequent primary anastomosis for left-sided lesions without preoperative bowel preparation. Although success rates are good with this approach, we still feel that unstable patients should undergo resection and diversion, either with an end colostomy or with primary anastomosis and a diverting loop ileostomy.

If a definitive bleeding site has not been located on any preoperative testing then the procedure of choice is a total abdominal colectomy with ileorectal anastomosis. As long as the rectum is devoid of solid stool, an anastomosis can be safely performed even in the absence of preoperative bowel preparation. The anastomosis should be at the level of the sacral promontory and special care should be taken to preserve the superior rectal artery in ensure adequate blood supply to the anastomosis. Most patients generally tolerate this procedure very well and fears of postoperative diarrhea are as a whole unwarranted. Although several loose bowel movements per day are to be expected, continence is generally not a problem because the rectum is left entirely intact. Those patients who do complain of incapacitating diarrhea generally respond well to antimotility agents such as Immodium or Lomitil.

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